Please list all nonprescription medications and supplements you are presently taking and for what reason.

Do you take any prescription medications?
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Yes No

Please list each prescription medication you take and for what reason, along with the name and phone number of the doctor who prescribed it.

Please check all items that have been areas of concern in the last 6 months.

Aggression Anger Anorexia, binge eating, purging Anxiety or worry Being so fidgety or restless that you have been moving around a lot more than usual Chronic pain Confusion Constant suspicion Craving alcohol or other drugs Feeling down, depressed, or hopeless Disorganized, racing, or unusual thoughts Dizziness Euphoric mood Excessive energy Excessive spending Fears or phobias Feeling bad about yourself, feeling you are a failure, or feeling you have let yourself or your family down Feeling restless or wired Feeling tired or having little energy Financial or legal problems Gambling problems Having little interest or pleasure in doing things Impulsive behavior Irritable mood Less need for sleep Mood swings Moving or speaking so slowly that other people could have noticed Obsessions or compulsions Panic attacks Physical health problems Poor impulse control Sexual problems Tremors or tics Trouble concentrating on things such as reading the newspaper or watching television Trouble falling asleep, staying asleep, or sleeping too much Weight or appetite increase/decrease Emotional or verbal abuse Physical abuse Sexual abuse Hearing or seeing things that others don’t Thoughts of harming another person Thinking that you would be better off dead or that you want to hurt yourself in some way

Have you ever thought about or attempted suicide?
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Yes No

Please describe when this happened and what was going on in your life.
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Do you use alcohol or recreational drugs?
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Yes No

For each, please describe the type of alcohol or drug, how much you have, and how often.
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Please check any of the following that describe your experiences with alcohol or other drugs.
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I feel I have a problem with alcohol or other drugs. Others feel I have a problem with alcohol or other drugs. My drinking/drug use has caused problems in my family or relationships. My drinking/drug use has caused problems in my job. It is difficult for me to stop or control the amount I take. I have been arrested for a DUI or related offense. I have been in treatment for substance use. A family member has been in treatment for substance use. None of the above

If you are in a relationship, please describe the nature of the relationship and how many months or years you have been together.

Please describe your current living situation. Who else lives in your home?
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Do you have any children?
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Yes No

For each child, please list name, age, and how you get (or got) along.
*

Do you have any siblings?
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Yes No

For each sibling, please list name, age, and how you get (or got) along.
*

Please describe your relationship with your mother. What was it like when you were a child? What is it like now?
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Please describe your relationship with your father. What was it like when you were a child? What is it like now?
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Please describe your relationships with any others who played a significant role in helping to raise you (stepparents, grandparents, etc.).

Who among your family, friends, and others are part of your emotional support system?
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What do you consider to be your strengths?
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What else would you like me to know?

Negative Cycles

In close relationships, we all get caught sometimes in “negative cycles” of interaction, despite both people's best intentions and efforts. You react to the other person’s reactions, and the other person reacts to your reactions, and round and round you go in a feedback loop, with both of you hurting.

There is always a lot more going on than you can see on the surface. This exercise can help us begin to understand the underlying feelings that drive the negative cycles you get caught in, which is the first step toward changing them.

You can get caught in different cycles with different people. As you complete this exercise, please think about a specific relationship in your life that you would like to understand and perhaps change. If you are coming in for counseling with another person, please complete this exercise as it relates to that person.

To better focus on the behaviors, thoughts, and feelings that matter the most to you, please choose no more than 5 options for each question or sentence completion.

This is the cycle I get caught in with
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Name of other person

When something happens between us and I feel disconnection, conflict, or tension with you, most often my reaction is to
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Ask questions, push you to respond, or try to get your attention Plead, pursue, cling, or try to get close Complain Insist on making my point Correct, remind, or try to change you Interrupt you Raise my voice Disapprove, criticize, or blame you Provoke, prod, attack, or threaten Stay calm, reason, analyze, or problem solve Move away, turn to a task, joke, or change the subject Defend myself, make excuses, minimize your concerns, or show you are wrong Push the feelings away Placate, give in, or give up Get quiet, withdraw, not respond, or put up a wall Zone out, shut you out, or not listen Stop the conversation Use alcohol, drugs, porn, gambling, shopping, overeating, or similar

I do this in the hope that
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We will avoid conflict I will persuade you to respond to me more

In our circular dance, YOU seem to then
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Ask questions, push me to respond, or try to get my attention Plead, pursue, cling, or try to get close Complain Insist on making your point Correct, remind, or try to change me Interrupt me Raise your voice Disapprove, criticize, or blame me Provoke, prod, attack, or threaten Stay calm, reason, analyze, or problem solve Move away, turn to a task, joke, or change the subject Defend yourself, make excuses, minimize my concerns, or show I am wrong Push the feelings away Placate, give in, or give up Get quiet, withdraw, not respond, or put up a wall Zone out, shut me out, or not listen Stop the conversation Use alcohol, drugs, porn, gambling, shopping, overeating, or similar

I'm on the edge of a cliff There is a wall between us Sandpaper is rubbing on my heart I'm hanging by a thread My tether is cut I'm knocking and knocking on the door I'm in the doghouse I'm out in the cold, alone I'm reaching into emptiness I've been sent to sit in the corner I'm walking on eggshells I need my copilot I'm walking on broken glass The bridge between us is broken I’m going behind a wall I’m forgotten I'm a deer in the headlights I’m left behind I'm armoring up I'm getting crumbs I've been convicted of a crime

The catastrophic thing I then say to myself is
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I'm all alone I'm too much It's always my fault I'm not good enough I can never please you You don’t care about me You’re never there for me I’m not important to you I’m going to lose you I can’t take this anymore We’re not going to make it

Deep down, I am really longing for you to
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Reassure me Value me See me Tell me I’m special to you Hold me and help me Be there for me Tell me you love me Accept me Validate me Tell me I can count on you Support me See that I am trying and doing the best I can Comfort me Help me to feel safe Tell me I’m special to you, you value our relationship, and I’m number one with you. Want me as a partner and lover. Love and accept me with my feelings and imperfections. Need me and want me close. Care about my feelings, hurts, and needs. Be there for me, and not leave me alone when I need you the most. Hear and respect me, not dismiss me or leap into thinking the worst of me. Give me a chance to learn how to be with you. Tell me I can count on you to hear me and put everything else aside. Tell me I can ask you to hold me, and understand that just asking is very hard for me.

Without meaning to, each of us often deals with disconnection in a way that scares the other person and pushes him or her farther away. The coping style I tend to use in moments of distress is
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Protest: I move toward you, protesting the disconnection and requesting (or demanding!) connection. (Sadly, this pursuit might come across to you as alarming anger and criticism, rather than an attempt to heal the relationship.) Distance: I move away from you, trying to avoid painful conflict and not feel my unmet need for connection. (Sadly, this withdrawal can be seen by you as an alarming lack of love, rather than an attempt to protect the relationship and both of us from further damage.)

When each person’s response to disconnection inadvertently alarms the other and increases the distance between us, a vicious circle ensues. Like a whirlpool, this circle pulls us both in and is very hard to escape! Overall, the cycle that feels the closest to what happens in our relationship is
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The more I protest, the more you distance – and the more you distance, the more I protest and pursue. The more I distance, the more you protest – and the more you protest and pursue, the more I distance. We both pursue. The more each person feels criticized, the more he or she defends by criticizing back. We both distance. The more distant and unapproachable each person appears, the more the other withdraws.

Thank you for providing this information in preparation for our first session. I look forward to working with you!